Clinical Consequences of Congenital Heart Disease - Congestive Heart Failure

Which congenital heart defects have the potential of causing heart failure?

All of them. Some are relatively more severe, and are therefore more likely to cause heart failure, but they all can eventually cause, or contribute to the development of, heart failure.

Is it typical for a child in heart failure to only show signs of right-sided heart failure, or to only show signs of left-sided heart failure?

No, children with heart failure will typically show signs of left-sided and right-sided heart failure, regardless of the origin of the problem.

Which congenital heart defects have the potential of causing heart failure?

All of them. Some are relatively more severe, and are therefore more likely to cause heart failure, but they all can eventually cause, or contribute to the development of, heart failure.

Is it typical for a child in heart failure to only show signs of right-sided heart failure, or to only show signs of left-sided heart failure?

No, children with heart failure will typically show signs of left-sided and right-sided heart failure, regardless of the origin of the problem.

How does heart failure affect vital signs?

Increased heart rate, increased respiratory rate, decreased blood pressure, decreased oxygen saturation

If the left ventricle is failing to push an adequate amount of blood out to the body, what clinical manifestations would you expect?

Fatigue, inappropriate sweating, decreased urinary output, pale and cool extremities with weak pulses and decreased blood pressure

If heart failure is causing fluid to back up in the pulmonary circulation, what clinical manifestations would you expect?

The usual signs of respiratory distress (tachypnea, dyspnea, increased work of breathing), as well as crackles and wheezing

If heart failure is causing fluid to back up in the systemic circulation, what clinical manifestations would you expect?

Hepatomegaly, weight gain, edema, ascites, neck vein distention

If there is a buildup of fluid in the systemic circulation, where in the body is this typically first noticeable?

Around the eyes (periorbital edema)

How does heart failure affect weight?

This is a bit tricky to answer. Heart failure causes weight gain because of the fluid retention. But heart failure also makes it difficult for children to have the energy to grow, so children with CHD are typically small in terms of weight for age, and for many of them, gaining weight is a major goal.

How does digoxin affect heart rate?

It decreases heart rate, which is why you should never give it to a bradycardic patient.

What is the advantage of digoxin over other inotropes, such as dopamine or milrinone?

Digoxin is the only inotrope that can be administered orally at home, the others are given in the acute care setting

How do ACE inhibitors affect potassium?

They cause an increase in potassium, which is why children on ACE inhibitors typically do not take potassium supplements or potassium-sparing diuretics, and their potassium levels are monitored regularly.

What is the therapy used to eliminate excess water and salt to prevent reaccumulation?

The administration of diuretics, such as furosemide (Lasix), chlorothiazide (Diuril), and spironolactone (Aldactone)

How does serum potassium level affect the effectiveness of digoxin?

They are inversely correlated. That is, digoxin is extra effective when potassium level is low, and digoxin is less effective when potassium level is high. This is why it is important to monitor potassium for anyone taking digoxin.

How are fluid restrictions different in infants compared to adults?

Fluid restrictions are rarely needed in infants because of how difficult it is for children to feed adequately.

How are sodium-restricted diets different in children compared to adults?

They are used less often and/or less strictly, because of the negative effect on the child's appetite.

How is oxygen administration different for children with congenital heart disease?

Nurses should be extra careful with oxygen, as there are some cases where children with a low oxygen saturation can be harmed by oxygen, and children with cyanotic heart defects will have a low oxygen saturation no matter how much oxygen you give them

How is the heart rate parameter for digoxin different in children?

Digoxin should never be given to a bradycardic patient because it lowers heart rate. Because children have a higher heart rate in general, the threshold at which they are considered bradycardic is higher. In adults, digoxin is held if the heart rate is below 60

The nurse is administering digoxin to a child. The order states that the drug should be held for any heart rate below 70 beats per minute. This child typically has a heart rate of 100-110 bpm, and 2 hours ago his heart rate was 105 bpm. He currently has a heart rate of 71 bpm. What should the nurse do?

Hold the dose and check to make sure that the heart rate is accurate. If it is accurate, notify the practitioner before proceeding. This is an example of a time when the nurse should use judgment. It isn't appropriate to give a medication that slows heart rate to a child who suddenly experienced a significant drop in heart rate.

How should the pulse be taken before giving digoxin?

Apical rate is auscultated for 1 full minute.

Why is it important to assess the parents' level of anxiety about giving digoxin?

If they are overly concerned about overdosing their child, they may withhold it excessively

To help the infant conserve energy, the nurse should make a schedule to maximize:

uninterrupted periods of sleep. Things like linen changes and baths, which are usually scheduled based on what is most time-efficient for the nurse, should instead be scheduled during times when the infant will be bothered anyway.

Is neck vein distention seen in infants with heart failure?

Neck vein distention is generally not seen in infants, simply because of their anatomy.

How can nurses promote the growth of infants with heart failure?

Infants grow when they eat more calories than they use, so nurses should increase calorie intake, while conserving energy

How can nurses increase caloric intake?

Switch from a normal formula to a high-calorie formula, and/or alternate between breastmilk and high-calorie formula, and/or supplement formula and breastmilk with calorie-dense things like oil

To help the infant conserve energy, stress should be minimized. What are some ways to reduce stress?

There are a variety of ways to do this. It could be simply explaining to older children what is happening, when, and why. In more extreme cases, especially with infants and young children, this could even include sedating them, if it's the only way it will keep them calm.

To help the infant conserve energy, when should the nurse feed the infant?

Soon after awakening, before the infant starts crying out of hunger, on a 3-hour schedule

What does "activity intolerance" look like in an infant?

Difficulty feeding, since feeding is the hardest job they have to do

To help the infant conserve energy, feeding sessions should last no longer than:

30 minutes. If the infant is not done feeding by this time, the rest of the food can go through a nasogastric tube (gavage feeding).

To help the infant conserve energy, how should the nurse modify feeding sessions?

Give the infant extra rest periods, and use a special nipple that makes it easier to suck, so they don't have to use a lot of energy. If the infant doesn't finish feeding because of these long rest periods, that's okay, the rest of the food can go through a nasogastric tube.

Why might an infant with a CHD require all feeding to happen through a nasogastric tube?

To conserve the energy that they would have used eating, so they have more energy leftover to grow